Download Physician`s Orders for Rituxan Infusion

RA
Rituxan
order form
Physician’s Orders for Rituxan Infusion
for patients with rheumatoid arthritis (RA)
For health care
professionals
INDICATION: Rituxan® (rituximab) in combination with methotrexate is indicated for the treatment of adult patients with moderately
to severely active rheumatoid arthritis who have had an inadequate response to one or more TNF antagonist therapies.
Rituxan is not recommended for treatment of patients with severe active infections.
Patient Information
Physician’s NAME
Patient’s name
Phone
Date of birth
Fax
Allergies
E-mail
Other relevant history
Premedication
Diphenhydramine (Dose
Route
)
Acetaminophen (Dose
Route
)
Glucocorticoid
(Dose
Route
)
For patients with RA, methylprednisolone 100 mg IV or its equivalent is recommended 30 minutes prior to each infusion.
Other
(Dose
Route
)
Rituxan dosing
Total Rituxan dose for each infusion
mg
Infusion frequency
For patients with RA, the Rituxan dose is 1000 mg on Day 1 and Day 15. For RA, Rituxan is given in combination with methotrexate.
PRN orders in the event of infusion reactions
Physician’s PRN orders
Medication
(Dose
Route
)
Medication
(Dose
Route
)
Additional instructions from the physician
Ordering Physician Signature
Ordering Physician Name (Print)
Date
CONTINUED ON REVERSE SIDE.
IMPORTANT SAFETY INFORMATION: Rituxan has been associated with fatal infusion reactions, tumor lysis syndrome (TLS),
severe mucocutaneous reactions, and progressive multifocal leukoencephalopathy (PML).
Other serious, potentially fatal adverse reactions include hepatitis B reactivation, other infections including bacterial, fungal, new
or reactivated viral infections, and cardiovascular events.
Common adverse reactions include infusion reactions and infections.
For additional safety information, please see the full prescribing information,
including BOXED WARNINGS and Medication Guide.
RA
Information About Infusion Reactions
Review Medication Guide with patient prior to each infusion.
If severe infusion reaction occurs
After the infusion
Make sure to follow your office’s or institution’s protocol for
identifying and managing infusion reactions.
Instruct
patients and family members or attendants
about symptoms to watch for and what actions to take
in the event of post-infusion symptoms such as1:
Interrupt the infusion
Medications
and supportive care measures should be
available and instituted as medically indicated for use
in the event of a reaction during administration.
These may include, but are not limited to:
IV fluids
Glucocorticoids
Antihistamines
Acetaminophen
Hives or rash
Weakness
Itching
Dizziness or
feeling faint
Swelling of the lips,
Palpitations
tongue, throat, or face
Sudden cough
Chest pain
Shortness of breath, difficulty breathing, or wheezing
Epinephrine
Bronchodilators
Oxygen
Instruct patients and family members or attendants to
seek immediate medical attention if they notice any of
the above symptoms
most cases, the infusion can be resumed at 50%
In
of the previous rate (eg, 100 mg/h to 50 mg/h) when
symptoms have completely resolved1
Common Adverse Events
In RA clinical trials, the most common adverse events with greater incidence in the group receiving Rituxan (n=540) vs the
placebo group (n=398) were hypertension (8% vs 5%), nausea (8% vs 5%), upper respiratory tract infection (7% vs 6%),
arthralgia (6% vs 4%), pyrexia (5% vs 2%), and pruritus (5% vs 1%). These data are based on 938 patients treated in phase
2 and 3 studies of Rituxan (2 x 1000 mg) or placebo administered in combination with methotrexate.
Fax-back infusion confirmation
Administration date
Administration time
Notes
Infusion Nurse Signature
Infusion Nurse Name (Print)
Date
Phone
Fax
E-mail
Reference: 1. Rituxan [package insert]. South San Francisco, CA: Biogen Idec Inc and Genentech USA, Inc; April 2011.
For additional safety information, please see the full prescribing information, including BOXED WARNINGS and Medication Guide.
© 2011 Genentech USA, Inc., So. San Francisco, CA and Biogen Idec Inc.,
Cambridge, MA RRA0000416300